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Younger Adults Face Pronounced Racial, Ethnic Gaps in Kidney Therapy
New sequence analysis suggests racial and ethnic disparities in KRT are pronounced in younger adults, affecting mortality, transplantation, and dialysis modality use.
New research highlights persistent racial and ethnic disparities among patients with kidney failure undergoing kidney replacement therapy (KRT), with differences most pronounced in younger adults.1
These findings reveal critical gaps across racial, ethnic, and age-based groups in mortality, transplantation, and dialysis modality use, although investigators stress the results do not imply causality.1
“While the USRDS annual data report provides statistics by race/ethnicity or age separately, it lacks statistics on their interaction,” wrote study investigator Jonathan Daw, PhD, an associate professor of sociology and demography at the Pennsylvania State University, and colleagues. “To address this issue, it is important to assess if racial/ethnic groups vary in their age patterns of KRT receipt, which could imply critical periods for antidisparity interventions.”1
Patients with kidney failure have several KRT options, including in-center dialysis, at-home dialysis, and kidney transplantation. Many patients experience multiple modalities over time, which can substantially affect quality of life and longevity. Although many patients prefer the convenience of home dialysis, in-center dialysis remains the most common option in the US.1,2
Access to these modalities, particularly home dialysis and living donor kidney transplant (LDKT), varies across racial and ethnic groups. These disparities are influenced by systemic, social, and interpersonal factors, including neighborhood disadvantage. However, longitudinal differences in KRT modality transitions and duration across diverse populations remain underexplored. Sequence analysis is an emerging methodology enabling holistic depictions of patients’ longitudinal KRT experiences.1,2
Building on this approach, Daw and colleagues conducted a sequence analysis using national registry data from the USRDS.1
The exposures were race/ethnicity, including non-Hispanic Asian American (Asian-NH), non-Hispanic African American or Black (Black-NH), Hispanic, and non-Hispanic White (White-NH), as well as the age groups 18 to 44 years and 45 to 64 years. The primary outcomes were 10-year kidney replacement therapy modality sequences: in-center dialysis, home dialysis, deceased donor kidney transplant [DDKT], LDKT, stopped dialysis, and mortality.1
Using sequence analysis, investigators characterized longitudinal KRT modality sequences using descriptive statistics and visualized them with state distribution plots stratified by race/ethnicity and age. No statistical significance tests were performed, with the reported differences reflecting real population-level patterns.1
The cohort included 50,776 adults, with 24% aged 18-44 years and 76% aged 45-64 years. Racial/ethnic composition was 3.6% Asian-NH, 35.8% Black-NH, 17.7% Hispanic, and 42.9% White-NH. Specifically:1
- Asian-NH: 1,824 (478 aged 18-44; 1,346 aged 45-64)
- Black-NH: 18,182 (4,889; 13,293)
- Hispanic: 8,999 (2,519; 6,480)
Racial/ethnic differences in KRT modality and mortality were most pronounced in younger adults. By month 120, cumulative mortality was:1
- Asian-NH: 23.2%
- Black-NH: 42.8%
- Hispanic: 29.2%
- White-NH: 40.7%
Among living patients, substantial differences in modality prevalence were observed. Functioning LDKTs were consistently most common in White-NH patients and least common in Black-NH patients:1
- Month 1: 6.5% Asian-NH, 1.4% Black-NH, 3.2% Hispanic, 8.7% White-NH
- Month 120: 19.2% Asian-NH, 4.3% Black-NH, 12.4% Hispanic, 21.3% White-NH
For DDKTs, percentages by month 120 were similar across Black-NH, Hispanic, and White-NH patients (20.8%, 23.8%, 22.0%, respectively), but White-NH patients more often received DDKT earlier (month 49: 7.9% Black-NH, 8.9% Hispanic, 16.9% White-NH).1
In-center dialysis use was increased among Asian-NH, Black-NH, and Hispanic patients than White-NH patients across the study period. Home dialysis use was increased among Asian-NH and White-NH patients compared with Black-NH and Hispanic patients in most periods.1
Among 45-64-year-olds, racial/ethnic differences in KRT modality were attenuated due to increased prevalence of in-center dialysis. This age-leveling effect was even more pronounced in the 65-74 and 75+ age groups, where in-center dialysis and mortality dominate the KRT trajectory.1
Sequence analysis revealed that the most common KRT modality sequence among 18-44-year-old Black-NH patients was in-center dialysis followed by mortality (C-M, 31.6%).1
“Patterns in KRT modality sequences offer a more nuanced view of racial/ethnic disparities in access to treatments for incident kidney failure,” the investigators concluded. “Future research should investigate these data in a sequence analysis framework to better understand the determinants and consequences of racial/ethnic and age differences in KRT modality patterns,” concluded investigators.1
